Iatrogenic aortic valve fenestration rupture following coronary angiography: a case report.

Background: Aortic valve fenestration (AVF) is a relatively common anatomical variation, while its rupture is a rare cause of aortic regurgitation (AR), especially following coronary angiography. This case report highlights the importance of echocardiographic evaluation and multidisciplinary discussion for the differential diagnosis of fibroelastoma or endocarditis. Case summary: A 66-year-old man presented with acute shortness of breath following coronary angiography for an inferior ST-elevation myocardial infarction. Echocardiography revealed severe aortic regurgitation associated with a filamentous mobile structure on the non-coronary cusp. A multidisciplinary discussion was conducted to determine the cause of the AR, leading to the patient undergoing aortic valve replacement. A gross inspection of the valve confirmed AVF rupture. Conclusion: Iatrogenic AVF rupture following coronary angiography is an exceptionally rare complication. Thorough echocardiographic evaluation plays a significant role in differentiating AVF rupture from other valve pathologies, such as fibroelastoma, Lambl's excrescence, or endocarditis. Echocardiographic features, including a very thin, linear, and flail-like mobile lesion, the paracommissural location, frequent involvement of the non-coronary cusp, and an eccentric jet of the AR, are suggestive of AVF rupture. While medical history and clinical examination contribute to the diagnostic process, definitive diagnosis relies on surgery and anatomopathology.

Critical Preoperative Hemoglobin Value to Predict Anemia-Related Complications After Cardiac Surgery.

OBJECTIVES: Preoperative anemia is frequent in patients undergoing cardiac surgery and is associated with increased postoperative complications. The purpose of this observational study was to estimate the critical preoperative hemoglobin threshold associated with the occurrence of complications after cardiac surgery. DESIGN: A retrospective observational cohort study. SETTING: A tertiary-care medical center from January 2019 to April 2020. PARTICIPANTS: A total of 1,004 patients undergoing elective cardiac surgery were included. INTERVENTIONS: None (observational study). MEASUREMENTS AND MAIN RESULTS: The primary study endpoint was to define the hemoglobin threshold that predicted the occurrence of postoperative major complications after elective cardiac surgery. Postoperative complications were a composite criterion, including transient ischemic attack or stroke, myocardial infarction, acute kidney injury, respiratory failure, mediastinitis, or mesenteric ischemia. A discrimination threshold was determined by using receiver operating characteristic curves. The discrimination threshold for hemoglobin concentration with the best sensitivity/specificity ratio for the occurrence of postoperative complications was 13 g/dL for male patients and 11.8 g/dL for female patients. The incidence of postoperative complications was 17.2% in the total population. Independent risks were preoperative hemoglobin concentration, red blood cell transfusion, European System for Cardiac Operative Risk Evaluation II, and the type of surgery. CONCLUSIONS: The critical preoperative hemoglobin thresholds associated with the occurrence of postoperative complications with the best sensitivity/specificity ratio were 13 g/dL for men and 11.8 g/dL for women, which were very similar to the World Health Organization criteria defining anemia.

Surgical Revascularization With Cardiopulmonary Bypass on a Patient With Severe COVID-19.

The coronavirus disease 2019 (COVID-19) may lead to an acute respiratory distress syndrome by an inappropriate cytokine response and may predispose to a prothrombotic state through multiple pathways. Both can complicate the management of cardiac surgery with cardiopulmonary bypass, which is known to activate the hemostatic system and to exacerbate systemic inflammatory response. Little is known about the impact of cardiac surgery with cardiopulmonary bypass on viral pneumonia, particularly with the new coronavirus. In this article, we describe the case of a diabetic patient with COVID-19 and a concomitant 3-vessel disease with a formal indication for surgical revascularization, who unexpectedly presented with a high heparin resistance during cardiopulmonary bypass. Emphasis is placed on the importance of multidisciplinary team discussions before surgery, on the thorough preoperative assessment, and on the perioperative management, particularly regarding mechanical ventilation and anticoagulation.

Thiopental versus propofol on the outcome of the newborn after caesarean section: An impact study.

BACKGROUND: In 2011, the company that produced thiopental in France and in the United States stopped its marketing. Because of limited evidences, the choice of the best induction agent for caesarean section remains controversial, especially in emergency. The objective of this study was to compare the effects of propofol versus thiopental on the Apgar score of the newborn. METHODS: Newborns delivered by elective or emergency caesarean section under general anaesthesia in a university hospital were included from January 2009 to December 2013. Two periods, according to the hypnotic drug used, were compared in this before-and-after comparative study: thiopental before May 2011 and propofol after. The primary outcome was to compare the proportion of newborns with a 5-minute Apgar Score < 7 between both groups. RESULTS: 367 newborns were enrolled, 178 in thiopental group and 189 in propofol group. Demographic and clinical characteristics were similar in both groups. The occurrence of a 5-minute Apgar Score less than 7 was not influenced by the use of propofol (OR 1.40 [CI 95% 0.90-2.20] P = 0.135). Blood gas analyses and admission's rate in neonatal intensive care unit were similar in both groups. CONCLUSIONS: Thiopental and propofol do not appear to present significant difference in term of outcome of the newborn after caesarean section. In this situation, propofol may probably be a reliable alternative to the supply reduction of thiopental imposed by forces. Prospective studies are required to confirm the safety of propofol, particularly in the long term.

Laparoscopic Rectopexy in a Patient With Pulmonary Hypertension Associated With Scleroderma: A Case Report.

We report the perioperative management of a patient with pulmonary hypertension under new-generation treatments who underwent laparoscopic surgery. Preoperatively, arterial catheter, central venous line, and transesophageal echocardiography probe were inserted in addition to standard monitoring. Intraoperatively, inhaled nitric oxide was used because of increasing pressure in the right heart chambers related to the Trendelenburg position and the pneumoperitoneum. The operation finally lasted <2 hours without complication. The prognosis of patients with pulmonary hypertension has evolved since the advent of new management strategies. Thorough preoperative assessment and multidisciplinary discussion in a referral center are essential for medical optimization.